Random pull practice RN NCLEX test

The nurse is teaching a class on nutrition and feeding practices for young children. What should the nurse recommend as the best snack for a toddler? - 1/2 cup orange juice - Dry, sweetened cereal - Raw carrot sticks - Slices of cheese

slices of cheese when considering foods for a toddler: - safety - nutrient density - potential for foodborne illness

A nurse is preparing to administer an oxytocin IV infusion to a client for induction. The nurse recognizes that an oxytocin infusion may increase the client's risk for which of the following? Select all that apply - Abnormal or indeterminate fetal heart rate patterns - Delayed breast milk production - Placenta previa - Postpartum hemorrhage - Uterine tachysytole.

- Abnormal or indeterminate fetal heart patterns - Postpartum hemorrhage - Uterine tachysystole.

What communication strategies would the nurse have in place when establishing rapport with the caregiver and an 8-year-old during a health history interview? Select all that apply. - Ask only closed-ended questions to obtain information - Allow the child to describe their current issue - Isolate the child from the parents and interview them separately - Maintain an eye level position when speaking with the child - Use language that both the child and caregiver can understand.

- Allow the child to describe their current issue - Maintain an eye level position when speaking with the child - Use language that both the child and caregiver can understand.

The nurse receives report on 4 clients. Which client should be seen first? - 10-month-old with audible congestion and mucus-producing cough - 10-year-old with an active nose bleed who is applying pressure - 12-year-old with urinary frequency and burning, and fever - 15-year-old with painful right hip, fever, and limited range of motion.

15-year-old with painful right hip, fever, and limited range of motion. Pain, limited range of motion, and fever indicate joint infection (septic joint). A septic hip is a surgical emergency as impaired blood supply may lead to permanent joint destruction, sepsis, and/or death. The nurse should expect management to include cultures, antibiotics, and surgical debridement.

A nurse is making a presentation on skin cancer prevention with special focus on melanoma at a community health forum. Which statements should the nurse include? Select all that apply - Apply a broad spectrum sunscreen before and during outdoor sports - Apply sunscreen a few minutes before starting outdoor activities - Reapply sunscreen after swimming, even if waterproof sunscreen was used earlier - Serious sunburns can occur even on overcast days - Use tanning beds for <15 minutes or less for a base tan that is less likely to burn.

- Apply a broad spectrum sunscreen before and during outdoor sports - Reapply sunscreen after swimming, even if waterproof sunscreen was used earlier - Serious sunburns can occur even on overcast days.

The nurse performs an initial assessment on a client with suspected post-traumatic stress disorder. Which assessment would support this diagnosis? Select all that apply. - Difficulty concentrating - Feeling detached from others - Feeling lethargic and apathetic - Flashbacks of the traumatic event - Persistent angry, fearful mood

- Difficulty concentrating - Feeling detached from others - Flashbacks of the traumatic events - Persistent angry, fearful mood.

The clinic nurse reinforces education about intimate partner violence for a group of graduate nurses. Which of the following are appropriate for the nurse to include? Select all that apply - Intimate partner violence is most common in low-income families - Intimate partner violence is rare in same-sex partnerships - The abusive partner often demonstrates jealousy and possessiveness - Victims may not leave due to financial concerns or fear of harm by the abuser - Violence against a female often intensifies during pregnancy

- The abusive partner often demonstrates jealousy and possessiveness - Victims may not leave due to financial concerns or fear of harm by the abuser - Violence against a female often intensifies during pregnancy

A client with a history of diverticular disease is being discharged after an episode of acute diverticulitis. Which instructions should be included in the discharge teaching plan to reduce the risk of future episodes? Select all that apply - Drink plenty of fluids - Exercise regularly - Follow a low-residue diet - Include whole grains, fruits, and vegetables in the diet - Increase intake of red meat

- Drink plenty of fluids - Exercise regularly - Include whole grains, fruits, and vegetables in the diet. Drinking fluid, exercising, and including whole grains, fruits and vegetables help prevent constipation, which can cause excess intracolonic pressure and increase the risk of diverticula forming and becoming inflamed. A low-residue diet, which avoids all high-fiber foods, may be used in treating acute diverticulitis, however, after symptoms have resolved, a high-fiber diet is resumed to prevent future episodes. Consumption of red meat and high-fat foods can increase the risk.

The nurse practicing in an outpatient clinic cares for a client recently diagnosed with hyperthyroidism. Which diet-related teaching should the nurse add to the client's plan of care? Select all that apply. - Emphasize the importance of a low-carbohydrate diet - Encourage the client to increase high-fiber foods in the diet - Include meals and snacks high in protein content - Teach avoidance of caffeine-containing liquids - Teach the client about consumption of a high-calorie diet of 4000-5000 calories/day

- Include meals and snacks high in protein content - Teach avoidance of caffeine-containing liquids. - Teach the client about consumption of a high-calorie diet of 4000-5000 calories/day Hyperthyroidism leads to an increased metabolic rate - satisfy hunger and prevent weight loss - high protein, high carbs, low fiber, no caffeine, no spicy foods.

Four clients come to the emergency department simultaneously. Which client should the nurse see first for definitive care? - 6-month-old with a temperature of 101 F who is rubbing the ears and being fussy - 10-day-old client with a red mark (stork bite) on the neck, the mother is concerned - A client who took a handful of amitriptyline pills, a tricyclic antidepressant drug - A client who tripped and hit the head but is alert with no loss of consciousness

A client who took a handful of amitriptyline pills - the actual amount taken and its effects are unknown - clients who deliberately OD often consume other substances that can potentiate the effect of the drug - OD on tricyclics are especially concerning due to the effect this can have on the cardiovascular and central nervous system - dysrhythmias, seizures

The charge nurse is notified that a client is being admitted with a diagnosis of active shingles with a disseminated rash. Which room assignment is most appropriate for this client? - A private room with contact and droplet precautions - A private room with negative airflow and airborne precautions - A private room with positive airflow and airborne precautions - A semi-private 2-bed room with standard precautions.

A private room with negative airflow and contact and airborne precautions. shingles that are open may transmit the infection by both air and contact. Negative airflow pulls air from the hospital environment into the room, and the air from the hospital room then goes directly to the outside rather than recirculating to the rest of the hospital

Cystic fibrosis

A protein responsible for transporting sodium and chloride is defective and causes the secretions from the exocrine glands to be thicker and stickier than normal. These abnormal secretions plug smaller airway passages and ducts in the GI tract. The thick secretions block pancreatic ducts, resulting in a deficient amount of pancreatic enzymes entering the bowel to aid in digestion and nutrient absorption. Clients require multiple vitamin supplements and supplemental pancreatic enzymes that are administered with meals. To meet growth expectations, clients with CF require a diet high in calories, fate, and protein.

A client's diabetes is controlled with a morning dose of glargine and a scheduled, fixed dose of lispro with meals. Before breakfast, the client's fingerstick glucose is 105 mg/dL. The tray is in the room, and the client is eager to eat. What action should the nurse take? - Administer both insulins as prescribed - Hold both glargine and lispro insulin - Hold the glargine insulin - Hold the lispro insulin

Administer both insulins as prescribed.

The home health nurse is providing care for a 6-year-old client who has a tracheostomy and is being mechanically ventilated when the ventilator's apnea alarm sounds. The nurse finds the client to be unresponsive and pulseless, and there are no other caregivers present. Which action should the nurse take first? - Begin chest compressions - Deliver 2 breaths using a bag valve device connected to the tracheostomy - Locate and apply an automated external defibrillator - Use a phone to call 911

Begin chest compressions.

Four clients come to the emergency department and are assessed by the triage nurse. Which client should be prioritized for more definitive care? - Client with history of gout who has severe pain in the right foot. - Client with history of migraines reporting headache and photophobia - Client with severe epigastric pain radiating to the back after an alcohol binge - Client with sudden onset of the "worst headache of my life."

Client with sudden onset of the "worst headache of my life."

The nurse prepares to administer a dose of radioactive iodine (RAI) to a 39-year-old female client with Grave's disease. Which action is most important for the nurse to take? - Ask client when her last menstrual cycle occurred - Confirm pregnancy test result is negative - Obtain a baseline assessment of the mouth and throat - Teach the client the signs and symptoms of hypothyroidism.

Confirm pregnancy test result is negative.

A child with attention-deficit hyperactivity disorder (ADHD) has been taking methylphenidate for a year. What are the priority nursing assessments when the client comes to the clinic for a well-child visit? - Attention span and activity level - Dental health and mouth dryness - Height/weight and blood pressure - Progress with schoolwork and in making friends

Height/weight and BP - A common side effect of methylphenidate (Ritalin, Concerta) is loss of appetite with resulting weight loss. it is very important to compare weight/height measurements from one well-child checkup to the next. If weight loss becomes a serious problem, methylphenidate can be given after meals, however, before meals is preferable.

The nurse teaching the parents of a child diagnosed with cystic fibrosis will advise the parents to choose foods that satisfy which recommended diet? - Gluten-free with added protein - High calorie, high protein, high fat - High protein, low fat, low phosphate - High protein, low fat, low sodium

High calorie, high protein, high fat. Cystic fibrosis causes damage to the GI tract and pancreas, leading to impaired absorption of nutrients and resulting growth deficits. Clients must consume a diet high in calories, fate, and protein.

The parents of a hospitalized preschooler are concerned because their toilet-trained child has started wetting the bed. Which response by the nurse is most helpful? - Discipline your child by taking away playroom privileges - It is normal for your child to regress while hospitalized - Restricting fluids at nighttime will solve this problem - Your child is acting out due to the hospitalization

It is normal for your child to regress while hospitalized.

Acrocyanosis

Peripheral cyanosis of the hands and fee is a benign finding during a newborn's transition to extrauterine life. It is especially common during the first 24 hours of life or in the first week if the newborn is cold. Manifestations include a bluish discoloration of the hands and feet and sometimes the skin surrounding the mouth. Results from poor perfusion to the periphery of the body, an initial mechanism to reduce heat loss and stabilize temperature Initial nursing management includes promoting thermoregulation by placing the newborn skin-to-skin with the mother or under a radiant warmer and assessing axillary temperature

Syphilis in pregnancy

Screening: universal at first prenatal visit; third trimester and delivery if high risk Serologic tests: nontreponemal; treponemal Treatment: IM penicillin G benzathine Pregnancy effects: intrauterine fetal demise; preterm labor Fetal effects: hepatic (hepatomegaly, jaundice); Hematologic (hemolytic anemia, decreased platelets); Musculoskeletal (long bone abnormalities); failure to thrive

The nurse caring for a 48-year-old executive on the cardiac unit who had just been diagnosed with primary hypertension. Which teaching strategy implemented by the nurse is most likely to be effective for this client? - Leave diet pamphlets for the client to review at a later time - Refer the client to the nurse case manager to follow up with diet instructions - Sit with the client during meal selections and assist with identification of low sodium options - Turn the television on in the client's room to the patient education channel to watch

Sit with the client during meal selections.

An elderly client has a 17-mm induration after a tuberculin skin test (TST). Based on this result, which statement is most accurate? - The client has a false-positive reaction due to advanced age - The client has a tuberculosis (TB) infection - The client has active TB disease - The client must be isolated immediately

The client has a tuberculosis (TB) infection

The nurse observes a client self-administering nasal fluticasone. Which observation would require the nurse to intervene and provide further teaching? - A sitting position is assumed as the head is bowed slightly forward - The client points the spray tip toward the nasal septum during instillation - The nasal spray tip is inserted into the nostril as the other nostril is occluded - While administering the medication, the client inhales deeply through the nose.

The client points the spray tip toward the nasal septum during installation

The graduate nurse (GN) is caring for a client at 20 weeks gestation with secondary syphilis. The client reports an allergic reaction to penicillin as a child, but does not know what kind of reaction occurred. When discussing the client's potential treatment plan with the precepting nurse, which statement by the GN indicates an appropriate understanding? - Doxycycline is an acceptable alternative to penicillin for treatment of syphilis during pregnancy - The client will require penicillin desensitization to receive appropriate treatment - The newborn can be treated after birth if antepartum treatment is contraindicated - Treatment is only effective if provided during the primary stage of syphilis.

The client will require penicillin desensitization to receive appropriate treatment. The only adequate prenatal treatment is IM penicillin injection. Expected outcomes include resolution of maternal infection and prevention or treatment of fetal infection. If a pregnant client has a penicillin allergy, the nurse should anticipate penicillin desensitization so that adequate treatment can be provided.

The nurse caring for a terminally ill client asks if the client has an advance directive. The client states, "I already have a power of attorney." What is the best response by the nurse? - A power of attorney (POA) is good to have in place. It sounds like you are on the right track - Great. Your POA can start to make decisions for you when you are no longer able to do so - Many people find a lawyer at this stage of life. A lawyer can help you get your affairs in order - There are many types of POAs. Let's clarify if your POA can make health care decisions for you.

There are many types of POAs. Let's clarify if your POA can make health decisions for you.

The nurse performing an initial newborn assessment observes a bluish discoloration of the hands and feet. The trunk has a pink color. Which action by the nurse is appropriate? - Apply blow-by oxygen and count respirations - Auscultate heart sounds for a murmer - Observe the newborn for expiratory grunting - Place the newborn skin-to-skin with the mother.

place the newborn skin-to-skin with the mother.